Treatment Type 2 Diabetes Mellitus Patients

ABSTRACT

A pharmaceutical combination for use in glycemic control in a type 2 diabetes mellitus patient, said combination comprising (i) lixisenatide or/and a pharmaceutically acceptable salt thereof, (ii) insulin glargine or/and a pharmaceutically acceptable salt thereof, and (iii) optionally metformin or/and a pharmaceutically acceptable salt thereof.

Subject of the present invention is a pharmaceutical combination for use in glycemic control, for use in the reduction of the HbA1c value, the fasting plasma glucose or/and the 2 hour postprandial plasma glucose, for use in the prevention of weight gain or/and for inducing weight loss, for use in the reduction of the risk of hypoglycemia, in a type 2 diabetes mellitus patient, said combination comprising

(i) lixisenatide or/and a pharmaceutically acceptable salt thereof,

(ii) insulin glargine or/and a pharmaceutically acceptable salt thereof, and

(iii) optionally metformin or/and a pharmaceutically acceptable salt thereof.

In a healthy person the release of insulin by the pancreas is strictly coupled to the concentration of blood glucose. An increased level of blood glucose, as appears after meals, is rapidly counterbalanced by a respective increase in insulin secretion. In fasting condition the plasma insulin level drops to a basal value which is sufficient to ensure the continuous supply of glucose to insulin-sensitive organs and tissues and to keep the hepatic glucose production at a low level at night.

In contrast to type 1 diabetes, there is not generally a lack of insulin in type 2 diabetes mellitus but in many cases, particularly in progressive cases, the treatment with insulin is regarded as the most suitable therapy, if required in combination with orally administered anti-diabetic drugs.

An increased glucose level in the blood over several years without initial symptoms represents a significant health risk. It could clearly be shown by the large-scale DCCT study in the USA (The Diabetes Control and Complications Trial Research Group (1993) N. Engl. J. Med. 329, 977-986) that chronically increased levels of blood glucose are a main reason for the development of diabetes complications. Examples for diabetes complications are micro and macrovascular damages that possibly manifest themselves in retinopathies, nephropathies or neuropathies and lead to blindness, renal failure and the loss of extremities and are accompanied by an increased risk of cardiovascular diseases. It can thus be concluded that an improved therapy of diabetes primarily has to aim keeping blood glucose in the physiological range as close as possible.

A particular risk exists for overweight patients suffering from type 2 diabetes mellitus, e.g. patients with a body mass index (BMI)≧30 kg/m². In these patients the risks of diabetes overlap with the risks of overweight, leading e.g. to an increase of cardiovascular diseases compared to type 2 diabetes mellitus patients being of a normal weight.

The compound desPro³⁶Exendin-4(1-39)-Lys₆-NH₂ (AVE0010, lixisenatide) is a derivative of Exendin-4. AVE0010 is disclosed as SEQ ID NO:93 in WO 01/04156:

SEQ ID NO: 1: lixisenatide (44 amino acids) H-G-E-G-T-F-T-S-D-L-S-K-Q-M-E-E-E-A-V-R-L-F-I-E- W-L-K-N-G-G-P-S-S-G-A-P-P-S-K-K-K-K-K-K-NH₂ SEQ ID NO: 2: exendin-4 (39 amino acids) H-G-E-G-T-F-T-S-D-L-S-K-Q-M-E-E-E-A-V-R-L-F-I-E- W-L-K-N-G-G-P-S-S-G-A-P-P-P-S-NH₂

Exendins are a group of peptides which can lower blood glucose concentration. The Exendin analogue lixisenatide is characterised by C-terminal truncation of the native Exendin-4 sequence. Lixisenatide comprises six C-terminal lysine residues not present in Exendin-4.

Lixisenatide is also termed des-38-proline-exendin-4(He/oderma suspectum)-(1-39)-peptidylpenta-L-lysyl-L-lysinamide (CAS number 320367-13-3). In the present invention, “lixisenatide” includes pharmaceutically acceptable salts thereof. The person skilled in the art knows suitable pharmaceutically acceptable salts of lixisenatide.

Insulin glargine is an analogue of human insulin. Insulin glargine is 31^(B)-32^(B)-Di-Arg human insulin with further substitution of asparagine in position A21 by glycine. Insulin glargine is also termed Gly(A21)-Arg(B31)-Arg(B32) human insulin. The CAS number of insulin glargine is 160337-95-1. In the present invention, “insulin glargine” includes pharmaceutically acceptable salts thereof. The person skilled in the art knows suitable pharmaceutically acceptable salts of insulin glargine.

Metformin is the international nonproprietary name of 1,1-dimethylbiguanide (CAS number 657-24-9). Metformin is a biguanide hypoglycemic agent used in the treatment of non-insulin-dependent diabetes mellitus (type 2 diabetes mellitus) not responding to dietary modification. Metformin improves glycemic control by improving insulin sensitivity and decreasing intestinal absorption of glucose. Metformin is usually administered orally. However, control of type 2 diabetes mellitus in obese patients by metformin may be insufficient. Thus, in these patients, additional measures for controlling type 2 diabetes mellitus may be required. “Metformin”, as used herein, included pharmaceutically acceptable salts thereof. The person skilled in the art knows suitable pharmaceutically acceptable salts of metformin.

In the examples of the present invention, the effect of the combination of lixisenatide, insulin glargine and optionally metformin has been tested in obese type 2 diabetes mellitus patients poorly controlled with a basal insulin alone or a basal insulin in combination with one to three oral anti-diabetic drugs selected from metformin, sulfonylureas, dipeptidyl-peptidase-4 (DPP-4) inhibitors and glinides. Even by this treatment, the diabetes patients still had a fasting plasma glucose concentration of about 9.2 to 9.5 mmol/L and a HbA1c value of about 8.5%. The 2 hour postprandial plasma glucose was about 13.8 to 14.5 mmol/L (249 to 262 mg/dL). These values still exceed normoglycemic values.

Surprisingly, a reduction in fasting glucose plasma concentration to about 6.6 mmol/L (119 mg/dL) could be observed by treatment with a combination of lixisenatide, insulin glargine and optionally metformin. Reduction of body weight was statistically superior for lixisenatide in view of the comparative treatment with insulin glulisine once daily or three times daily.

Termination of the above-indicated pre-treatment and titration of insulin glargine (optionally in combination with metformin) for 12 weeks to achieve a glycemic target of 4.4 to 5.6 mmol/L in terms of fasting SMPG without recurrent or severe hypoglycemia before the onset of treatment with the combination of lixisenatide, insulin glargine and optionally metformin resulted in an initial reduction in fasting glucose plasma concentration from 9.16 mmol/L to 6.91 mmol/L and in HbA1c from 8.51% to 7.87%.

Documented hypoglycemia was numerically and significantly lower with lixisenatide in view of the comparative treatment with insulin glulisine once daily or three times daily.

In conclusion, insulin glargine combined with lixisenatide and optionally metformin may become a preferred option, attaining meaningful glycemic targets with less hypoglycemia and with weight loss compared with prandial insulin (such as insulin glulisine), as basal insulin plus oral anti-diabetic compounds or basal insulin plus prandial insulin (bolus administration) in difficult to control, obese, insulin-treated type 2 diabetes mellitus patients.

A first aspect of the present invention is a pharmaceutical combination for use in glycemic control in a type 2 diabetes mellitus patient, said combination comprising

(i) lixisenatide or/and a pharmaceutically acceptable salt thereof,

(ii) insulin glargine or/and a pharmaceutically acceptable salt thereof, and

(iii) optionally metformin or/and a pharmaceutically acceptable salt thereof.

In this aspect, the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone.

As demonstrated by the Example disclosed herein, the combination as described herein can be used for improving glycemic control. In the present invention, “improvement of glycemic control” or “glycemic control” in particular refers to improvement of the 2 hour postprandial plasma glucose concentration, improvement of fasting plasma glucose concentration, or/and improvement of the HbA_(1c) value.

In particular, “improvement of glycemic control” or “glycemic control” includes the improvement of the 2 hour postprandial plasma glucose concentration.

In particular, “improvement of glycemic control” or “glycemic control” includes the reduction of the 2 hour postprandial plasma glucose concentration. Reduction means in particular that the 2 hour postprandial plasma glucose concentration reaches normoglycemic values or at least approaches these values.

In particular, “improvement of glycemic control” or “glycemic control” includes the improvement of the fasting plasma glucose concentration.

In particular, improvement of fasting plasma glucose concentration includes the reduction of the fasting plasma glucose concentration. Reduction means in particular that the fasting plasma glucose concentration reaches normoglycemic values or at least approaches these values.

In particular, “improvement of glycemic control” or “glycemic control” includes the improvement of the HbA_(1c) value.

In particular, improvement of the HbA_(1c) value includes the reduction of the HbA_(1c) value. Reduction of the HbA_(1c) value in particular means that the HbA_(1c) value is reduced below 6.5% or 7%.

Yet another aspect of the present invention is a pharmaceutical combination for use in the improvement of the HbA1c value, the fasting plasma glucose or/and the 2 hour postprandial plasma glucose in a type 2 diabetes mellitus patient, said combination comprising

(i) lixisenatide or/and a pharmaceutically acceptable salt thereof,

(ii) insulin glargine or/and a pharmaceutically acceptable salt thereof, and

(iii) optionally metformin or/and a pharmaceutically acceptable salt thereof.

In this aspect, the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone.

In the present invention, normoglycemic values are blood glucose concentrations of in particular 60-140 mg/d1 (corresponding to 3.3 to 7.8 mmol/L). This range refers in particular to blood glucose concentrations under fasting conditions and postprandial conditions.

Criteria for a type 2 diabetes mellitus diagnosis include:

-   -   the fasting plasma glucose concentration (FPG) is ≧7.0 mmol/L         (126 mg/dl), or     -   the post challenge plasma glucose concentration is >11.1 mmol/L         (200 mg/dl), performed as described by the World Health         Organization (Definition, Diagnosis and Classification of         Diabetes Mellitus and its Complications. Part 1: Diagnosis and         Classification of Diabetes Mellitus. WHO/NCD/NCS/99.2. Geneva;         1999), using a glucose load containing the equivalent of 75 g         anhydrous glucose dissolved in water, or     -   symptoms of diabetes and a casual plasma glucose ≧200 mg/dl         (11.1 mmol/L).

These criteria are described in the Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence (International Diabetes Federation, ISBN 2-930229-72-1).

The diagnosis of Type 2 Diabetes should not be based on a single plasma glucose concentration. Diagnosis may require continued observation with fasting or/and postprandial blood glucose levels or/and an oral glucose tolerance test.

According to Craig (Type 2 diabetes mellitus Diabetes 2014: 15(Suppl. 20): 4-17), fasting plasma glucose (FPG) and post challenge (postload) glucose can be classified as follows:

-   -   FPG<5.6 mmol/L (100 mg/dL)=normal fasting glucose concentration.     -   FPG 5.6 to 6.9 mmol/L (100-125 mg/dL)=impaired fasting glucose         concentration.     -   FPG≧7.0 mmol/L (126 mg/dL)=provisional diagnosis of diabetes         (the diagnosis must be confirmed, as described above)

The corresponding categories when the Oral Glucose Tolerance Test (OGTT) is used, are as follows:

-   -   Two hour postload glucose<7.8 mmol/L (140 mg/dL)=normal glucose         tolerance.     -   Two hour postload glucose 7.8 to <11.1 mmol/L (140-200         mg/dL)=impaired glucose tolerance.     -   Two hour postload glucose≧11.1 mmol/L (200 mg/dL)=provisional         diagnosis of diabetes (the diagnosis must be confirmed, as         described above).

Impaired glucose tolerance (IGT) and impaired fasting glucose concentration (IFG) are intermediate stages in the natural history of disordered carbohydrate metabolism between normal glucose homeostasis and diabetes.

In the present invention, normoglycemic values of fasting plasma glucose are blood glucose concentrations of in particular <5.6 mmol/L.

In the present invention, normoglycemic values of postprandial plasma glucose, as defined herein, are blood glucose concentrations of in particular <7.8 mmol/L.

In the present invention, “not adequately controlled” by a particular anti-diabetic treatment means that this treatment is not sufficient to remove the symptoms of type 2 diabetes mellitus. In particular, “not adequately controlled” by this treatment means that the patient does not reach normoglycemic values in terms of, for example, 2 hour postprandial plasma glucose concentration, HbA1c value or/and fasting plasma glucose concentration.

The type 2 diabetes mellitus patient to be treated according to the present invention may be a subject suffering from type 2 diabetes mellitus, wherein type 2 diabetes mellitus is not adequately controlled by treatment with a basal insulin monotherapy.

The type 2 diabetes mellitus patient to be treated according to the present invention may be a subject suffering from type 2 diabetes mellitus, wherein type 2 diabetes mellitus is not adequately controlled by treatment with a combination of a basal insulin and metformin alone, for instance with (a) a dose of at least 1.0 g/day metformin or at least 1.5 g/day metformin for at least 3 months, or/and (b) a dose of at the maximum 2.0 g/day metformin for at least 3 months or at the maximum 3.5 g/day metformin for at least 3 months.

The type 2 diabetes mellitus patient to be treated according to the present invention may be a subject suffering from type 2 diabetes mellitus, wherein the type 2 diabetes mellitus to be treated is not adequately controlled with compound (b) and optionally compound (c) alone.

By the treatment according to the present invention, adequate control of type 2 diabetes mellitus may be achieved in type 2 diabetes mellitus patients not adequately controlled by a particular treatment, as described herein.

“Basal insulin”, as used herein, includes insulin glargine, insulin detemir and isophane insulin (NPH insulin). The basal insulin is in particular selected from insulin glargine, insulin detemir and isophane insulin (NPH insulin).

As used herein, “to be treated according to the present invention”, “treatment according to the present invention”, or “therapy according to the present invention” relates to the treatment of a type 2 diabetes mellitus patient by the pharmaceutical combination comprising

(i) lixisenatide or/and a pharmaceutically acceptable salt thereof,

(ii) insulin glargine or/and a pharmaceutically acceptable salt thereof, and

(iii) optionally metformin or/and a pharmaceutically acceptable salt thereof,

as described herein.

A further aspect of the present invention is a pharmaceutical combination for use in the prevention of weight gain or/and for inducing weight loss, in a type 2 diabetes mellitus patient, said combination comprising

(i) lixisenatide or/and a pharmaceutically acceptable salt thereof,

(ii) insulin glargine or/and a pharmaceutically acceptable salt thereof, and

(iii) optionally metformin or/and a pharmaceutically acceptable salt thereof.

In this aspect, the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone.

The examples of the present invention demonstrate that the claimed combination can reduce body weight in type 2 diabetes patients, as defined herein, wherein the comparative treatment (insulin glulisine once daily or three times daily) induces a significant weight gain.

Yet another aspect of the present invention is a pharmaceutical combination for use in the reduction of the risk of hypoglycemia, in a type 2 diabetes mellitus patient, said combination comprising

(i) lixisenatide or/and a pharmaceutically acceptable salt thereof,

(ii) insulin glargine or/and a pharmaceutically acceptable salt thereof, and

(iii) optionally metformin or/and a pharmaceutically acceptable salt thereof.

In this aspect, the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone.

The examples of the present invention demonstrate that documented hypoglycemia was numerically and significantly lower with the claimed combination in view of the comparative treatment with insulin glulisine once daily or three times daily.

Hypoglycemia is the critical limiting factor in the glycemic management of diabetes in both the short and long term. Despite steady improvements in the glycemic management of diabetes, population-based data indicate that hypoglycemia continues to be a major problem for people with both type 1 and type 2 diabetes (American diabetes association, workgroup on hypoglycemia: Defining and Reporting Hypoglycemia in Diabetes. Diabetes Care 28(5), 2005, 1245-1249).

The combination of the present invention can prevent hypoglycemia when administered to a type 2 diabetes mellitus patient, as described herein. “Prevention of hypoglycemia” includes reduction of the number of hypoglycemic events and/or the severity of hypoglycemia events. The combination as described herein is suitable for use in the prevention of hypoglycemia.

In the present invention, hypoglycemia is a condition wherein a type 2 diabetes mellitus patient experiences a plasma glucose concentration of below 70 mg/dL (or below 3.9 mmol/L), below 60 mg/dL (or below 3.3 mmol/L), below 54 mg/dL (or below 3.0 mmol/L), below 50 mg/dL, below 40 mg/dL, or below 36 mg/dL.

In the present invention, “symptomatic hypoglycemia” or “symptomatic hypoglycemic event” is a condition associated with a clinical symptom that results from the hypoglycemia, wherein the plasma glucose concentration can be below 70 mg/dL (or below 3.9 mmol/L), below 60 mg/dL (or below 3.3 mmol/L), below 54 mg/dL (or below 3.0 mmol/L), below 50 mg/dL, or below 40 mg/dL. A clinical symptom can be, for example, sweating, palpitations, hunger, restlessness, anxiety, fatigue, irritability, headache, loss of concentration, somnolence, psychiatric disorders, visual disorders, transient sensory defects, transient motor defects, confusion, convulsions, and coma. In the present invention, one or more clinical symptoms of symptomatic hypoglycemia, as indicated herein, can be selected. Symptomatic hypoglycemia may be associated with prompt recovery after oral carbohydrate administration. A symptomatic hypoglycemia event preferably has a plasma glucose concentration of below 60 mg/dL (or below 3.3 mmol/L).

In the present invention, “severe symptomatic hypoglycemia” or “severe symptomatic hypoglycemic event” is a condition with a clinical symptom, as indicated herein, that results from hypoglycemia, wherein the plasma glucose concentration can be below 70 mg/dL (or below 3.9 mmol/L), below 54 mg/dL (or below 3.0 mmol/L) or below 36 mg/dL (or below 2.0 mmol/L). Severe symptomatic hypoglycemia can be associated with acute neurological impairment resulting from the hypoglycemic event. In a severe symptomatic hypoglycemia, the patient may require the assistance of another person to actively administer carbohydrate, glucagon, or other resuscitative actions. These episodes may be associated with sufficient neuroglycopenia to induce seizure, unconsciousness or coma. Plasma glucose measurements may not be available during such an event, but neurological recovery attributable to the restoration of plasma glucose to normal is considered sufficient evidence that the event was induced by a low plasma glucose concentration. A severe symptomatic hypoglycemia event preferably has a plasma glucose concentration of below 36 mg/dL (or below 2.0 mmol/L).

The definition of severe symptomatic hypoglycemia may include all episodes in which neurological impairment is severe enough to prevent self-treatment and which were thus thought to place patients at risk for injury to themselves or others. The acute neurological impairment may be at least one selected from somnolence, psychiatric disorders, visual disorders, transient sensory defects, transient motor defects, confusion, convulsions, and coma. “Requires assistance” means that the patient could not help himself or herself. Assisting a patient out of kindness, when assistance is not required, should not be considered a “requires assistance” incident.

Severe symptomatic hypoglycemia may be associated with prompt recovery after oral carbohydrate, intravenous glucose, or/and glucagon administration.

In the present invention, “documented symptomatic hypoglycemia” or “documented symptomatic hypoglycemic event” is an event during which typical symptoms of hypoglycemia accompanied by a measured plasma glucose concentration of 5. 70 mg/dL (5. 3.9 mmol/L), or less than or equal to 54 mg/dL (5 3.0 mmol/L). Clinical symptoms that are considered to result from a hypoglycemic episode are, e.g., increased sweating, nervousness, asthenia/weakness, tremor, dizziness, increased appetite, palpitations, headache, sleep disorder, confusion, seizures, unconsciousness, coma.

In the present invention, “asymptomatic hypoglycemia” or “asymptomatic hypoglycemic event” is an event not accompanied by typical symptoms of hypoglycemia but with a measured plasma glucose concentration less than or equal to 70 mg/dL (3.9 mmol/L), or less than or equal to 54 mg/dL (3.0 mmol/L).

In the present invention, “probable symptomatic hypoglycemia” or “probable symptomatic hypoglycemic event” is an event during which symptoms of hypoglycemia are not accompanied by a plasma glucose determination, but was presumably caused by a plasma glucose concentration less than or equal to 70 mg/dL (or less than or equal to 3.9 mmol/L), or less than or equal to 54 mg/dL (or less than or equal to 3.0 mmol/L); symptoms treated with oral carbohydrate without a test of plasma glucose.

In the present invention, “relative hypoglycemia” or “relative hypoglycemic event” is an event during which the person with diabetes reports any of the typical symptoms of hypoglycemia, and interprets the symptoms as indicative of hypoglycemia, but with a measured plasma glucose concentration greater than 70 mg/dL (or greater than 3.9 mmol/L).

In the present invention, the hypoglycemia can be a symptomatic hypoglycemia, a severe symptomatic hypoglycemia, a documented symptomatic hypoglycemia, a probable symptomatic hypoglycemia, a relative symptomatic hypoglycemia, or an asymptomatic hypoglycemia. Preferred is a symptomatic hypoglycemia, more preferably a severe symptomatic hypoglycemia. “Reducing the risk of hypoglycemia”, as used herein, can include reducing the incidence of hypoglycemia. The incidence of hypoglycemia per patient year can be computed per patient as: 365.25×(number of episodes of hypoglycemia)/(number of days exposed) and summarized by type of event and treatment group. “Reducing the risk of hypoglycemia”, as used herein, can further include prevention of hypoglycemia in a patient, when the formulation described herein is administered to a type 2 diabetes mellitus patient, as described herein. “Reducing the risk of hypoglycemia”, as used herein, can further include reduction of the number of hypoglycemic events, and/or the severity of hypoglycemia events.

The type 2 diabetes mellitus patient suffering from type 2 diabetes mellitus to be treated according to the present invention may be obese. A patient can be considered as obese if the body mass index is at least 30 kg/m². In the present invention, an obese type 2 diabetes mellitus patient may have a body mass index of at least 30 kg/m². The obese type 2 diabetes mellitus patient may have a body weight of at least 87 kg, at least 88 kg, at least 89 kg or at least 90 kg. The type 2 diabetes mellitus patient may be obese prior to the onset of therapy with the combination according to the present invention.

The patient to be treated may have an age of less than 50 years. The patient may also have an age of at least 50 years, or an age in the range of 50 to 64 years. The patient may also have an age of at least 65 years, or an age in the range of 65 to 74 years. The patient may also have an age of at least 75 years. It is preferred that the patient has an age of at least 65 years.

The type 2 diabetes mellitus to be treated according to the present invention may suffer from a type 2 diabetes mellitus not adequately controlled with a basal insulin monotherapy or a basal insulin and one to three oral anti-diabetics alone selected from the group consisting of metformin, a sulfonylurea, a DPP-4 inhibitor or a glinide alone. In this context, the basal insulin is in particular selected from insulin glargine, insulin detemir and isophane insulin (NPH insulin). In addition, this type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone.

The type 2 diabetes mellitus patient to be treated according to the present invention may have a fasting plasma glucose of at least 9 mmol/L or at least 9.5 mmol/L when treated with a basal insulin monotherapy or a basal insulin and one to three oral anti-diabetics alone selected from the group consisting of metformin, a sulfonylurea, a DPP-4 inhibitor or a glinide alone. In particular, the patient may have this fasting plasma glucose of at least 9 mmol/L L or at least 9.5 mmol/L prior to the onset of therapy with the combination according to the present invention. In this context, the basal insulin is in particular selected from insulin glargine, insulin detemir and isophane insulin (NPH insulin). In addition, this type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone.

Prior to the onset of therapy with the combination according to the present invention, the patient may have a fasting plasma glucose in the range of 5.6 to 6.9 mmol/L when treated with compound (b) and optionally compound (c) alone. This range can be considered to be an impaired fasting plasma glucose concentration.

Prior to the onset of therapy with the combination according to the present invention, the patient may have a fasting plasma glucose of at least 6.6 mmol/L, at least 6.7 mmol/L, at least 6.8 mmol/L or at least 6.9 mmol/L, when treated with compound (b) and optionally compound (c) alone.

The type 2 diabetes mellitus patient to be treated according to the present invention may have a HbA1c of at least 8.5% when treated with a basal insulin monotherapy or a basal insulin and one to three oral anti-diabetics alone selected from the group consisting of metformin, a sulfonylurea, a DPP-4 inhibitor or a glinide alone. In particular, the patient may have this a HbA1c of at least 8.5% prior to the onset of therapy with the combination according to the present invention. In this context, the basal insulin is in particular selected from insulin glargine, insulin detemir and isophane insulin (NPH insulin). In addition, this type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone.

Prior to the onset of therapy with the combination according to the present invention, the patient may have a HbA1c of at least 7.5% or at least 7.8% when treated with compound (b) and optionally compound (c) alone.

In particular, the patient to be treated according to the present invention does not receive concomitant treatment with at least one of a sulfonylurea, a DPP-4 inhibitor and a glinide.

In particular, in the patient to be treated according to the present invention, the type 2 diabetes mellitus has been diagnosed for at least 1 year or at least 2 years prior to the onset of a therapy according to the present invention.

The administration of the combination according to the present invention can comprise the steps:

-   -   (i) administration of compounds (b) and (c) for at least 4         weeks, and     -   (ii) continuing treatment by administration of compounds         (a), (b) and (c),

wherein the amount of compound (b) to be administered in steps (i) or/and (ii) is adjusted (titrated) so that a predetermined fasting plasma glucose level or/and a predetermined self-monitored plasma glucose level is reached or at least approximated. In particular, adjustment (titration) of compound (b) is performed in steps (i).

In step (i), the compounds (b) and (c) of the pharmaceutical combination of the present invention may be administered for at least 4 weeks, at least 8 weeks, at least 12 weeks, or at least 16 weeks. Preferably, step (i) comprises administration of compounds (b) and (c) for at least about 12 weeks.

Step (i) may be performed for at the maximum about 8 weeks, at the maximum about 12 weeks, at the maximum about 16 weeks, at the maximum about 20 weeks, or at the maximum about 24 weeks. Preferred is a duration of step (i) of about 12 weeks.

Step (i) may be performed with the proviso that compound (a) is not administered. As demonstrated by the Example of the present invention, a treatment with a combination of insulin glargine, lixisenatide and optionally metformin can improve fasting plasma glucose concentration, HbA_(1c) value, body weight and the risk of hypoglycemia if the treatment starts with administration of insulin glargine and optionally metformin alone. By this treatment protocol, the dose of insulin glargine can be reduced.

In the pharmaceutical composition of the present invention, the amount of compound (b) to be administered in steps (i) or/and (ii) is adjusted so that a predetermined fasting plasma glucose level or/and a predetermined self-monitored plasma glucose level is reached or at least approximated. The amount of compound (b) to be administered in steps (i) or/and (ii) may be adjusted on the basis of daily measurements of plasma glucose concentration. In particular the amount of compound (b) to be administered in steps (i) or/and (ii) may adjusted so that

-   -   (I) a fasting plasma glucose level or/and a fasting         self-monitored plasma glucose level of about 4.4 mmol/l to about         5.6 mmol/l, or/and     -   (II) a self-monitored plasma glucose level (SMPG) of about 7.8         mmol/l (or about 140 mg/dl) or less

is reached or at least approximated.

“Self-monitored plasma glucose (SMPG)”, as used herein, can be the “4-point Self Monitored Plasma Glucose” or the “7-point Self Monitored Plasma Glucose”. The 4 point and 7-point Self Monitored Plasma Glucose value are in particular average plasma glucose concentrations including fasting and postprandial conditions.

“4-point Self Monitored Plasma Glucose” in particular refers to the measurement of plasma glucose four times a day and calculation of the average plasma glucose concentration therefrom. In particular, the 4-point Self Monitored Plasma Glucose measurements are performed pre-breakfast, post-breakfast, pre-dinner, and post-dinner.

“7-point Self Monitored Plasma Glucose” in particular refers to the measurement of plasma glucose seven times a day and calculation of the average plasma glucose concentration therefrom. In particular, the 7-point Self Monitored Plasma Glucose measurements are performed pre-breakfast, post-breakfast, pre-lunch, post-lunch, pre-dinner, post-dinner and at bed-time.

The “fasting self-monitored plasma glucose (SMPG)”, as used herein, is measured by the patient before breakfast, in particular before insulin glargine or/and lixisenatide injection and optional intake of metformin.

In the present invention, a type 2 diabetes mellitus patient may have a HbA1c value in the range of 7% to 10%. In particular the type 2 diabetes mellitus patient to be treated may have a HbA_(1c) value of at least about 7%, at least about 7.5%, at least about 7.8%, at least about 8%, at least about 8.5%, or at least about 9%. These values exceed normoglycemic values, indicating that the type 2 diabetes mellitus is not adequately controlled if treated with an antidiabetic compound, as described herein.

The type 2 diabetes mellitus patient to be treated according to the present invention may have a 2 hours postprandial plasma glucose concentration of at least 11.1 mmol/L, at least 12 mmol/L, at least 13 mmol/L, at least 13.5 mmol/L or at least 14 mmol/L. These plasma glucose concentrations exceed normoglycemic concentrations, indicating that the type 2 diabetes mellitus is not adequately controlled if treated with an antidiabetic compound, as described herein.

“Postprandial” is a term that is well known to a person skilled in the art of diabetology. The term “postprandial” describes in particular the phase after an ingestion of a meal or/and exposure to glucose under experimental conditions. In a healthy person this phase is characterised by an increase and subsequent decrease in blood glucose concentration. The postprandial phase typically ends up to 2 h after a meal or/and exposure to glucose (2 h postprandial plasma glucose concentration).

Determination of postprandial plasma glucose is well-known (see, e.g. Crapo et al., Diabetes, 1977, 26(12):1178-1183).

The type 2 diabetes mellitus patient to be treated according to the invention may have a fasting plasma glucose concentration of at least 8 mmol/L, at least 8.5 mmol/L, at least 9 mmol/L, or at least 9.5 mmol/L. These plasma glucose concentrations exceed normoglycemic concentrations, indicating that the type 2 diabetes mellitus is not adequately controlled if treated with an antidiabetic compound, as described herein.

In the present invention, metformin can be administered according to commonly known administration protocols of metformin in accordance with the terms of marketing authorization. For example, metformin can be administrated once daily, twice daily or three times a day. In particular, the metformin dose applied before the onset of the therapy as disclosed herein is continued in combination with (a) lixisenatide or/and a pharmaceutically acceptable salt thereof, and (b) insulin glargine or/and a pharmaceutically acceptable salt thereof, as disclosed herein.

In the present invention, metformin may be administered orally. The skilled person knows formulations of metformin suitable for treatment of type 2 diabetes mellitus by oral administration. Metformin may be administered to a type 2 diabetes mellitus patient in need thereof, in an amount sufficient to induce a therapeutic effect. Metformin may be administered in a dose of at least 1.0 g/day or at least 1.5 g/day. Metformin may be administered in a dose of at the maximum of 2.0 g/day or at the maximum of 3.5 g/day. The daily metformin dose can be divided into two or three separate doses. For oral administration, metformin may be formulated in a solid dosage form, such as a tablet or pill. Metformin may be formulated with suitable pharmaceutically acceptable carriers, adjuvants, or/and auxiliary substances.

In the present invention, lixisenatide or/and a pharmaceutically acceptable salt may be administered in an add-on therapy to administration of insulin glargine and optionally metformin.

In the present invention, the terms “add-on”, “add-on treatment” and “add-on therapy” relate to treatment according to the present invention with insulin glargine and lixisenatide, and optionally metformin. Metformin, insulin glargine or/and lixisenatide each may be administered in a once-a-day-dosage. Metformin, insulin glargine and lixisenatide may be administered by different administration routes. Metformin may be administered orally, and lixisenatide and insulin glargine may be administered parenterally.

In particular, “add-on”, “add-on treatment” and “add-on therapy” mean that the dose of metformin administered before the onset of the treatment according to the present invention, as disclosed herein, can be continued in the treatment of the present invention.

In the present invention, lixisenatide includes pharmaceutically acceptable salts thereof. The person skilled in the art knows suitable pharmaceutically acceptable salts of lixisenatide. A preferred pharmaceutically acceptable salt of lixisenatide employed in the present invention is the acetate salt of lixisenatide.

In the present invention, lixisenatide or/and the pharmaceutically acceptable salt thereof may be administered to a type 2 diabetes mellitus patient in need thereof, in an amount sufficient to induce a therapeutic effect.

In the present invention, lixisenatide or/and the pharmaceutically acceptable salt thereof may be formulated with suitable pharmaceutically acceptable carriers, adjuvants, or/and auxiliary substances.

Lixisenatide or/and a pharmaceutically acceptable salt thereof may be administered parenterally, e.g. by injection (such as by intramuscular or by subcutaneous injection). Suitable injection devices, for instance the so-called “pens” comprising a cartridge comprising the active ingredient, and an injection needle, are known. Lixisenatide or/and a pharmaceutically acceptable salt thereof may be administered in a suitable amount, for instance in an amount in the range of 10 μg to 20 μg per dose.

In the present invention, lixisenatide or/and a pharmaceutically acceptable salt thereof may be administered in a daily dose in the range of 10 μg to 20 μg. Lixisenatide or/and a pharmaceutically acceptable salt thereof may be administered by one injection per day. Lixisenatide or/and a pharmaceutically acceptable salt thereof may be administered about 30 min before breakfast.

In the present invention, lixisenatide or/and a pharmaceutically acceptable salt thereof may be provided in a liquid composition, which preferably is an aqueous formulation. It is preferred that the liquid composition is suitable for parenteral administration, in particular for injection. The skilled person knows such liquid compositions of lixisenatide. A liquid composition of the present invention may have an acidic or a physiologic pH. An acidic pH preferably is in the range of pH 1-6.8, pH 3.5-6.8, or pH 3.5-5. A physiologic pH preferably is in the range of pH 2.5-8.5, pH 4.0-8.5, or pH 6.0-8.5. The pH may be adjusted by a pharmaceutically acceptable diluted acid (typically HCl) or pharmaceutically acceptable diluted base (typically NaOH).

The liquid composition comprising lixisenatide or/and a pharmaceutically acceptable salt thereof may comprise a suitable preservative. A suitable preservative may be selected from phenol, m-cresol, benzyl alcohol and p-hydroxybenzoic acid ester. A preferred preservative is m-cresol.

The liquid composition comprising lixisenatide or/and a pharmaceutically acceptable salt thereof may comprise a tonicity agent. A suitable tonicity agent may be selected from glycerol, lactose, sorbitol, mannitol, glucose, NaCl, calcium or magnesium containing compounds such as CaCl₂. The concentration of glycerol, lactose, sorbitol, mannitol and glucose may be in the range of 100-250 mM. The concentration of NaCl may be up to 150 mM. A preferred tonicity agent is glycerol.

The liquid composition comprising lixisenatide or/and a pharmaceutically acceptable salt thereof may comprise methionine from 0.5 μg/mL to 20 μg/mL, preferably from 1 μg/ml to 5 μg/ml. Preferably, the liquid composition comprises L-methionine.

In the present invention, insulin glargine or/and a pharmaceutically acceptable salt thereof may be provided in a liquid composition, which preferably is an aqueous formulation. It is preferred that the liquid composition is suitable for parenteral administration, in particular for injection. The skilled person knows such liquid compositions of insulin glargine.

Surfactants can be added to pharmaceutical formulation comprising insulin glargine, for example, inter alia, non-ionic surfactants. In particular, pharmaceutically customary surfactants are preferred, such as, for example: partial and fatty acid esters and ethers of polyhydric alcohols such as of glycerol, sorbitol and the like (Span®, Tween®, in particular Tween® 20 and Tween® 80, Myrj®, Brij®), Cremophor® or poloxamers. The surfactants are present in the pharmaceutical composition in a concentration of 5-200 μg/ml, preferably of 5-120 μg/ml and particularly preferably of 20-75 μg/ml.

The formulation comprising insulin glargine or/and a pharmaceutically acceptable salt thereof can additionally contain preservatives (e.g. phenol, m-cresol, p-cresol, parabens), isotonic agents (e.g. mannitol, sorbitol, lactose, dextrose, trehalose, sodium chloride, glycerol), buffer substances, salts, acids and alkalis and also further excipients. These substances can in each case be present individually or alternatively as mixtures.

Glycerol, dextrose, lactose, sorbitol and mannitol can be present in the pharmaceutical formulation comprising insulin glargine or/and a pharmaceutically acceptable salt thereof in a concentration of 100-250 mM, NaCI in a concentration of up to 150 mM. Buffer substances, such as, for example, phosphate, acetate, citrate, arginine, glycylglycine or TRIS (i.e. 2-amino-2-hydroxymethyl-1,3-propanediol) buffer and corresponding salts, can be present in a concentration of 5-250 mM, preferably 10-100 mM. Further excipients can be, inter alia, salts or arginine.

The zinc concentration of the formulation comprising insulin glargine or/and a pharmaceutically acceptable salt thereof is in the range of the concentration which is reached by the presence of 0-1000 μg/mL, preferably 20-400 μg/mL zinc, most preferably 90 μg/mL. However, the zinc may be present in form of zinc chloride, but the salt is not limited to be zinc chloride.

In the pharmaceutical formulation comprising insulin glargine or/and a pharmaceutically acceptable salt thereof glycerol and/or mannitol can be present in a concentration of 100-250 mmol/L, and/or NaCl is preferably present in a concentration of up to 150 mmol/L.

In the pharmaceutical formulation comprising insulin glargine or/and a pharmaceutically acceptable salt thereof a buffer substance can be present in a concentration of 5-250 mmol/L.

Insulin glargine or/and a pharmaceutically acceptable salt thereof can be present in the pharmaceutical formulation in a concentration of 60-6000 nmol/ml, preferably 240-3000 nmol/ml.

The pH of the formulation comprising insulin glargine or/and a pharmaceutically acceptable salt thereof can be in the range of pH 1-6.8, preferably pH 3.5-6.8, more preferred pH 3.5-4.5, even more preferred pH 4.0-4.5.

Yet another aspect of the present invention is the use of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

for the manufacture of a medicament for glycemic control in a type 2 diabetes mellitus patient, wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Yet another aspect of the present invention is the use of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

for the manufacture of a medicament for the improvement of the HbA1c value, the fasting plasma glucose or/and the 2 hour postprandial plasma glucose in a type 2 diabetes mellitus patient, wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Yet another aspect of the present invention is the use of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

for the manufacture of a medicament for the prevention of weight gain or/and for inducing weight loss in a type 2 diabetes mellitus patient, wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Yet another aspect of the present invention is the use of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

for the manufacture of a medicament for the reduction of the risk of hypoglycemia in a type 2 diabetes mellitus patient, wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Yet another aspect of the present invention is method for glycemic control in a type 2 diabetes mellitus patient, said method comprising administration of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Yet another aspect of the present invention is method for the improvement of the HbA1c value, the fasting plasma glucose or/and the 2 hour postprandial plasma glucose in a type 2 diabetes mellitus patient, said method comprising administration the use of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Yet another aspect of the present invention is method for the prevention of weight gain or/and for inducing weight loss in a type 2 diabetes mellitus patient, said method comprising administration the use of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Yet another aspect of the present invention is method for the reduction of the risk of hypoglycemia in a type 2 diabetes mellitus patient, said method comprising administration the use of a combination comprising

-   -   (a) lixisenatide or/and a pharmaceutically acceptable salt         thereof,     -   (b) insulin glargine or/and a pharmaceutically acceptable salt         thereof, and     -   (c) optionally metformin or/and a pharmaceutically acceptable         salt thereof,

wherein the type 2 diabetes mellitus to be treated preferably is not adequately controlled with compound (b) and optionally compound (c) alone. In this aspect, the patient may be a patient as defined herein.

Subject-matter of the present application is described in the following items:

-   -   1. A pharmaceutical combination for use in glycemic control, for         use in the reduction of the HbA1c value, the fasting plasma         glucose or/and the 2 hour postprandial plasma glucose, for use         in the prevention of weight gain or/and for inducing weight         loss, for use in the reduction of the risk of hypoglycemia, in a         type 2 diabetes mellitus patient, said combination comprising         -   (i) lixisenatide or/and a pharmaceutically acceptable salt             thereof,         -   (ii) insulin glargine or/and a pharmaceutically acceptable             salt thereof, and         -   (iii) optionally metformin or/and a pharmaceutically             acceptable salt thereof.     -   2. The pharmaceutical combination for use according to item 1,         wherein the type 2 diabetes mellitus to be treated is not         adequately controlled with compound (b) and optionally         compound (c) alone.     -   3. The pharmaceutical combination for use according to item 1 or         2, wherein the patient to be treated is obese.     -   4. The pharmaceutical combination for use according to any of         the preceding items, wherein the patient to be treated has a         body mass index of at least 30 kg/m².     -   5. The pharmaceutical combination for use according to any of         the preceding items, wherein the patient to be treated has an         age of at least 65 years.     -   6. The pharmaceutical combination for use according to any of         the preceding items, wherein prior to the onset of therapy with         the combination according to item 1, the patient has a fasting         plasma glucose of at least 9 mmol/L when treated with a basal         insulin monotherapy or a basal insulin and one to three oral         anti-diabetics alone selected from the group consisting of         metformin, a sulfonylurea, a DPP-4 inhibitor or a glinide alone.     -   7. The pharmaceutical combination for use according to any of         the preceding items, wherein prior to the onset of therapy with         the combination according to item 1, the patient has a fasting         plasma glucose concentration in the range of 5.6 to 6.9 mmol/L         or a fasting plasma glucose concentration of at least 6.6 mmol/L         when treated with compound (b) and optionally compound (c)         alone.     -   8. The pharmaceutical combination for use according to any of         the preceding items, wherein prior to the onset of therapy with         the combination according to item 1, the patient has a HbA1c of         at least 8.5% when treated with a basal insulin monotherapy or a         basal insulin and one to three oral anti-diabetics alone         selected from the group consisting of metformin, a sulfonylurea,         a DPP-4 inhibitor or a glinide alone.     -   9. The pharmaceutical combination for use according to any of         the preceding items, wherein prior to the onset of therapy with         the combination according to item 1, the patient has a HbA1c of         at least 7.5% when treated with compound (b) and optionally         compound (c) alone.     -   10. The pharmaceutical combination for use according to any of         the items 6 to 9, wherein the basal insulin is selected from         insulin glargine, insulin detemir and isophane insulin (NPH         insulin).     -   11. The pharmaceutical combination for use of any of the         preceding items, wherein the patient does not receive         concomitant treatment with at least one of a sulfonylurea, a         DPP-4 inhibitor and a glinide.     -   12. The pharmaceutical combination for use of any of the         preceding items, wherein in the patient to be treated, type 2         diabetes mellitus has been diagnosed for at least 1 year or at         least 2 years prior to the onset of a therapy with compounds         (a), (b) and optionally (c).     -   13. The pharmaceutical combination for use of any of the         preceding items, wherein the administration of the combination         comprises the steps:         -   (i) administration of compounds (b) and (c) for at least 4             weeks, and         -   (ii) continuing treatment by administration of compounds             (a), (b) and (c),         -   wherein the amount of compound (b) to be administered in             step (i) is adjusted so that a predetermined fasting plasma             glucose level or/and a predetermined self-monitored plasma             glucose level is reached or at least approximated.     -   14.The pharmaceutical combination for use according to item 13,         wherein the amount of compound (b) to be administered in         step (i) is adjusted so that         -   (I) a fasting plasma glucose level or/and a fasting             self-monitored plasma glucose level of about 4.4 mmol/l to             about 5.6 mmol/l, or/and         -   (II) a self-monitored plasma glucose level (SMPG) of about             7.8 mmol/l (or about 140 mg/dl) or less         -   is reached or at least approximated.     -   15. The pharmaceutical combination for use according to item 14,         wherein the self-monitored plasma glucose level in (II) is a         4-point self-monitored plasma glucose level or a 7-point         self-monitored plasma glucose level.     -   16. The pharmaceutical combination for use of any of the         preceding items, wherein lixisenatide or/and the         pharmaceutically acceptable salt thereof is prepared for         parenteral administration.     -   17.The pharmaceutical combination for use according to any of         the preceding items, wherein lixisenatide or/and the         pharmaceutically acceptable salt thereof is prepared for         administration in a daily dose selected from the range of 10 μg         to 20 μg.     -   18.The pharmaceutical combination for use according to any of         the preceding items, wherein insulin glargine or/and or/and the         pharmaceutically acceptable salt thereof is prepared for         parenteral administration.     -   19. The pharmaceutical combination for use of any of the         preceding items, wherein the metformin or/and the         pharmaceutically acceptable salt thereof is prepared for oral         administration.     -   20. A method for improving glycemic control, for the reduction         of the HbA1c value or/and the fasting plasma glucose, for use in         the prevention of weight gain or/and for inducing weight loss,         for use in the reduction of the risk of hypoglycemia, said         method comprising administering the combination of any one of         the items 1 to 18 to a subject in need thereof.     -   21. The method of item 20, wherein the type 2 diabetes mellitus         to be treated is not adequately controlled with compound (b) and         optionally compound (c) alone.     -   22. The method of item 20 or 21, wherein the subject is the         subject defined in any one of the items 2 to 15.

The invention is further illustrated by the following examples and figures.

FIGURE LEGENDS

FIG. 1—Plot of mean change in HbA1 c(%) from baseline by visit—mITT population

FIG. 2—Plot of mean change in body weight (kg) from baseline by visit—mITT population

FIG. 3—Plot of mean insulin glargine daily dose (U) by visit—mITT population

FIG. 4—Plot of mean daily insulin glulisine dose (U) by visit—mITT population

FIG. 5—Plot of mean total insulin dose (U) by visit—mITT population

FIG. 6—Graphical study design.¹ Insulin glargine should be injected subcutaneously once daily at dinner or breakfast time (according to patient's/investigators' preference). Injection time (dinner or breakfast) should be fixed at V2 and remain the same throughout the study.² Injection of lixisenatide should be performed 30-60 minutes prior to dinner or breakfast (the one associated with the highest self-monitored 2h-PPG median value across 3 different days). Meal used for lixisenatide dosing should remain the same throughout the 26-week treatment period.³ Injection of insulin glulisine should be done 0 to 15 minutes before dinner or breakfast (the one associated with the highest self-monitored 2h-PPG median value across 3 different days). Meal used for insulin glulisine dosing should remain the same throughout the 26-week treatment period.⁴ Injection of insulin glulisine prior to breakfast, lunch and dinner.

EXAMPLE 1

A randomized, open-label, active-controlled, 3-arm parallel-group, 26-week study comparing the efficacy and safety of lixisenatide to that of insulin glulisine once daily and insulin glulisine three times daily in patients with Type 2 diabetes insufficiently controlled with insulin glargine with or without metformin

1 Abbreviations

AE: Adverse event

ANCOVA: Analysis of covariance

BMI: Body mass index

CI: Confidence interval

CMH: Cochran-Mantel-Haenszel

ECG: Electrocardiogram

FPG: Fasting plasma glucose

GLP-1: Glucagon-like peptide-1

IMP: Investigational medicinal product

LOCF: Last observation carried forward

LS: Least square

mITT: Modified Intent-To-Treat

PG: Plasma glucose

PT: Preferred term

QD: Quaque die (Once a day)

SAE: Serious adverse event

SMPG: Self-measured plasma glucose

SOC: System organ class

TEAE: Treatment-emergent adverse event

TID: Ter in die (Three times a day)

2 Synopsis

3 Results

3.1 Study Patients

3.1.1 Patient Accountability

TABLE 1 Analysis populations Insulin Insulin Lixisenatide Glulisine QD Glulisine TID All Randomized population 298 (100%) 298 (100%) 298 (100%) 894 (100%) Efficacy population Modified Intent-to-Treat (mITT) 297 (99.7%) 298 (100%) 295 (99.0%) 890 (99.6%) Safety population 298 301 294 893 Note: The safety population patients are tabulated according to treatment actually received (as treated). For the other populations, patients are tabulated according to their randomized treatment.

3.1.2 Study Disposition

TABLE 2 Patient disposition - Randomized population Insulin Insulin Lixisenatide Glulisine QD Glulisine TID (N = 298) (N = 298) (N = 298) Randomized and not treated 0 0 1 (0.3%) Randomized and treated 298 (100%) 298 (100%) 297 (99.7%) Completed study treatment period 268 (89.9%) 281 (94.3%) 285 (95.6%) Did not complete study treatment period 30 (10.1%) 17 (5.7%) 12 (4.0%) Subject's decision for treatment discontinuation 18 (6.0%) 11 (3.7%) 8 (2.7%) Reason for treatment discontinuation Adverse event 14 (4.7%) 2 (0.7%) 5 (1.7%) Lack of efficacy^(a) 6 (2.0%) 4 (1.3%) 0 Poor compliance to protocol 0 3 (1.0%) 2 (0.7%) Lost to follow-up 0 0 0 Other reasons 9 (3.0%) 8 (2.7%) 5 (1.7%) ^(a)No rescue therapy was planned for the study, instead discontinuation was recommended if HbA1c value is above 8.5% at Week 12 or later on, and if appropriate corrective action fails and the repeated HbA1c 4 weeks later remains above 8.5%. Note: Percentages are calculated using the number of patients randomized as denominator.

3.1.3 Demographics and Baseline Characteristics

TABLE 3 Demographics and patient characteristics at screening or baseline - Randomized population Insulin Insulin Glulisine Glulisine Lixisenatide QD TID All (N = 298) (N = 298) (N = 298) (N = 894) Age (years) Number 298 298 298 894 Mean (SD)  59.8 (8.6)  60.2 (8.6)  59.4 (9.5)  59.8 (8.9) Median  60.0  60.0  60.0  60.0 Min:Max   35:79   35:78  32:87   32:87 Age group (years) [n (%)] Number 298 298 298 894  <50   39 (13.1%)   33 (11.1%)   48 (16.1%)   120 (13.4%) ≧50 to <65   170 (57.0%)   172 (57.7%)   154 (51.7%)   496 (55.5%) ≧65 to <75   76 (25.5%)   76 (25.5%)   85 (28.5%)   237 (26.5%) ≧75   13 (4.4%)   17 (5.7%)   11 (3.7%)   41 (4.6%) Gender [n (%)] Number 298 298 298 894 Male   138 (46.3%)   135 (45.3%)   132 (44.3%)   405 (45.3%) Female   160 (53.7%)   163 (54.7%)   166 (55.7%)   489 (54.7%) Race [n (%)] Number 298 298 298 894 Caucasian/White   276 (92.6%)   280 (94.0%)   272 (91.3%)   828 (92.6%) Black   13 (4.4%)   11 (3.7%)   12 (4.0%)   36 (4.0%) Asian/Oriental    9 (3.0%)    7 (2.3%)   13 (4.4%)   29 (3.2%) Other  0  0    1 (0.3%)    1 (0.1%) V1 (Week −14) HbA1c (%) Number 297 298 298 893 Mean (SD)  8.51 (0.72)  8.49 (0.72)  8.51 (0.78)  8.50 (0.74) Median  8.50  8.40  8.50  8.50 Min:Max  7.1:10.0  7.0:10.0  7.0:10.0  7.0:10.0 V7 (Week −1) HbA1c(%) Number 298 297 298 893 Mean (SD)  7.87 (0.53)  7.82 (0.52)  7.89 (0.54)  7.86 (0.53) Median  7.80  7.80  7.90  7.80 Min:Max  7.0:9.0  7.0:8.9  7.0:9.0  7.0:9.0 Randomization strata of HbA1c category (%) [n (%)] Number 298 298 298 894  <8%   172 (57.7%)   171 (57.4%)   172 (57.7%)   515 (57.6%) ≧8%   126 (42.3%)   127 (42.6%)   126 (42.3%)   379 (42.4%) Randomization strata of metformin use (%) [n (%)] Number 298 298 298 894 Yes   257 (86.2%)   258 (86.6%)   257 (86.2%)   772 (86.4%) No   41 (13.8%)   40 (13.4%)   41 (13.8%)   122 (13.6%) V2 (Week −12) FPG (mmol/L) Number 296 293 297 886 Mean (SD)  9.16 (2.94)  9.28 (2.88)  9.51 (2.96)  9.32 (2.93) Median  9.05  9.10  9.30  9.10 Min:Max  3.6:20.5  2.9:20.2  3.4:22.6  2.9:22.6 V7 (Week −1) FPG (mmol/L) Number 289 291 289 869 Mean (SD)  6.91 (2.07)  6.75 (1.80)  6.65 (1.86)  6.77 (1.91) Median  6.60  6.50  6.40  6.50 Min:Max  2.8:13.6  2.9:13.6  3.0:14.1  2.8:14.1 V2 (Week −12) Body Weight (kg) Number 298 298 298 894 Mean (SD) 89.75 (17.37) 87.93 (15.84) 89.66 (17.28) 89.11 (16.85) Median  88.20  87.55  87.75  88.00 Min:Max 54.1:155.8 51.0:132.8 46.4:152.0 46.4:155.8 Meal for IMP injection^(a) Number 298 298 Breakfast   90 (30.2%)   88 (29.5%) Dinner   207 (69.5%)   208 (69.8%) Missing    1 (0.3%)    2 (0.7%) BMI = Body Mass Index. ^(a)Meal for IMP injection as determined by 4-point SMPG, only presented for lixisenatide and insulin glulisine QD groups.

TABLE 4 Disease characteristics at screening or baseline - Randomized population Insulin Insulin Lixisenatide Glulisine QD Glulisine TID All (N = 298) (N = 298) (N = 298) (N = 894) Duration of diabetes (years) Number 298 298 298 894 Mean (SD) 11.89 (6.43)  12.33 (6.75) 12.41 (6.80)  12.21 (6.66)  Median 11.03 11.44 11.45 11.34 Min:Max 1.3:37.9 1.1:50.2 1.0:37.1 1.0:50.2 Duration of treatment with basal insulin treatment (years) Number 298 298 298 894 Mean (SD) 3.07 (2.64) 3.26 (3.46) 3.19 (3.13) 3.17 (3.09) Median 2.32 2.28 2.01 2.15 Min:Max 0.1:16.9 0.2:35.8 0.3:20.1 0.1:35.8 Daily dose of basal insulin by types at screening (U) Glargine Number 199 203 191 593 Mean (SD) 41.70 (23.23) 41.36 (23.35) 40.23 (22.73) 41.11 (23.08) Median 35.00 34.00 33.00 34.00 Min:Max 12.0:140.0 16.0:160.0 12.0:160.0 12.0:160.0 Detemir Number 25 32 30 87 Mean (SD) 41.00 (29.69) 39.59 (25.27) 39.43 (21.59) 39.94 (25.18) Median 32.00 30.00 35.00 32.00 Min:Max 20.0:160.0 18.0:120.0 20.0:125.0 18.0:160.0 NPH Number 74 63 77 214 Mean (SD) 40.61 (20.43) 38.97 (18.20) 40.92 (20.26) 40.24 (19.66) Median 33.00 36.00 36.00 34.50 Min:Max 20.0:116.0 16.0:100.0 16.0:116.0 16.0:116.0 Daily dose of insulin glargine at V2 (Week −12) (U) Number 298 298 298 894 Mean (SD) 40.92 (21.78) 39.83 (22.04) 39.46 (21.00) 40.07 (21.60) Median 34.00 34.00 34.50 34.00 Min:Max 16.0:134.0 16.0:160.0 12.0:160.0 12.0:160.0 Daily dose of insulin glargine at V8 (Week 0) (U) Number 292 295 296 883 Mean (SD) 67.88 (31.90) 64.72 (32.12) 65.14 (26.90) 65.91 (30.39) Median 62.00 58.00 60.83 60.00 Min:Max 13.0:192.0 14.0:205.3 18.0:204.0 13.0:205.3 Metformin use at screening [n (%)] Number 298 298 298 894 Yes  262 (87.9%)  260 (87.2%)  259 (86.9%)  781 (87.4%) No   36 (12.1%)   38 (12.8%)   39 (13.1%)  113 (12.6%) Daily dose of metformin at baseline (mg) Number 262 260 258 780 Mean (SD) 2069.37 (486.66)  2089.13 (477.03)  2114.15 (446.74)  2090.77 (470.31)  Median 2000.00 2000.00 2000.00 2000.00 Min:Max 500.0:3000.0 750.0:3400.0 850.0:3000.0 500.0:3400.0 GLP-1 = Glucagon like peptide-1.

3.1.4 Dosage and Treatment Compliance

TABLE 5 Treatment compliance - Safety population Lixisenatide Insulin Glulisine QD Insulin Glulisine TID (N = 298) (N = 301) (N = 294) Compliance rate (%) Number 297 301 294 Mean (SD) 99.34 (2.69) 98.72 (6.00) 97.12 (15.97) Median 100.00 100.00 100.00 Min:Max 68.2:102.7 44.4:113.3 0.0:298.4 Overall compliance [n (%)] Number 297 301 294 Patients with <60% 0 3 (1.0%) 4 (1.4%) Patients with ≧60% to <80% 2 (0.7%) 1 (0.3%) 12 (4.1%) Patients with ≧80% to ≦100% 294 (99.0%) 296 (98.3%) 273 (92.9%) Patients with >100% 1 (0.3%) 1 (0.3%) 5 (1.7%) Missing 1 0 0 IMP: Investigational Medicinal Product Note: Compliance rate (%) = (Total number of actual IMP injections for the dosing interval/Total number of expected IMP injections for the dosing interval) × 100.

3.2 Efficacy

3.2.1 Primary Efficacy Endpoint

TABLE 6 Mean change in HbA1c (%) from baseline to Week 26 - mITT population Lixisenatide Insulin Glulisine QD Insulin Glulisine TID HbA1c (%) (N = 297) (N = 298) (N = 295) Baseline Number 292 292 295 Mean (SD) 7.76 (0.56) 7.72 (0.58) 7.79 (0.60) Median 7.70 7.70 7.70 Min:Max 6.4:9.8 6.5:9.5   6.5:12.1 Week 26 (LOCF) Number 292 292 295 Mean (SD) 7.17 (0.77) 7.21 (0.79) 6.96 (0.73) Median 7.10 7.10 7.00 Min:Max 5.1:9.8  5.2:10.5 5.1:9.1 Change from baseline to Week 26 (LOCF) Number 292 292 295 Mean (SD) −0.59 (0.79)  −0.51 (0.80)  −0.82 (0.78)  Median −0.60 −0.50 −0.90 Min:Max −3.4:2.0  −2.6:2.5  −5.6:1.7  LS Mean (SE)^(a) −0.63 (0.054) −0.58 (0.054) −0.84 (0.053) LS Mean difference (SE) of Lixisenatide vs.^(ab) — −0.05 (0.059)  0.21 (0.059) 95% CI — (−0.170 to 0.064) (0.095 to 0.328) LOCF = Last observation carried forward. ^(a)Analysis of covariance (ANCOVA) model with treatment groups (lixisenatide, insulin glulisine QD, and insulin glulisine TID), Visit 7 (Week −1) strata of HbA1c [<8.0, ≧8.0%], randomization strata of metformin use, and country as fixed effects and baseline HbA1c value as a covariate. ^(b)Difference in LS Mean between lixisenatide vs. insulin glulisine QD, or lixisenatide vs. insulin glulisine TID. The analysis included measurements obtained up to 14 days after the last injection of the investigational medicinal product. Patients with both baseline and Week 26 (LOCF) measurements are included.

TABLE 7 Mean change in body weight (kg) from baseline to Week 26 - mITT population Lixisenatide Insulin Glulisine QD Insulin Glulisine TID Body weight (kg) (N = 297) (N = 298) (N = 295) Baseline Number 295 295 295 Mean (SD) 90.10 (17.39) 88.37 (15.88) 90.00 (17.21) Median    88.00    88.00    88.70 Min:Max 54.2:158.4 53.6:132.8 49.0:154.2 Week 26 (LOCF) Number 295 295 295 Mean (SD) 89.37 (18.14) 89.31 (16.27) 91.29 (17.27) Median    87.30    88.40    90.50 Min:Max 54.2:191.1 55.0:134.8 50.3:155.0 Change from baseline to Week 26 (LOCF) Number 295 295 295 Mean (SD) −0.72 (5.16)  0.94 (2.50) 1.29 (2.80) Median    −0.50    0.90    1.20 Min:Max −16.4:72.5  −8.2:10.9  −9.5:12.4  LS Mean (SE)^(a) −0.63 (0.276)  1.03 (0.276)  1.37 (0.271) LS Mean difference (SE) of Lixisenatide vs.^(ab) — −1.66 (0.305) −1.99 (0.305) 95% CI — (−2.257 to −1.062) (−2.593 to −1.396) p-value     <.0001     <.0001 LOCF = Last observation carried forward. ^(a)Analysis of covariance (ANCOVA) model with treatment groups (lixisenatide, insulin glulisine QD, and insulin glulisine TID), Visit 7 (Week −1) strata of HbA1c [<8.0, ≧8.0%], randomization strata of metformin use, and country as fixed effects and baseline body weight as a covariate. ^(b)Difference in LS Mean between lixisenatide vs. insulin glulisine QD, or lixisenatide vs. insulin glulisine TID. The analysis included measurements obtained up to 3 days after the last injection of the investigational medicinal product. Patients with both baseline and Week 26 (LOCF) measurements are included.

FIG. 1 shows the mean change in HbA1c(%) from baseline by visit in the mITT population. FIG. 2 shows the mean change in body weight (kg) from baseline by visit in the mITT population.

3.2.2 Other Key Efficacy Endpoints

TABLE 8 Mean change in fasting plasma glucose (mmol/L) from baseline to Week 26 - mITT population Fasting plasma glucose Lixisenatide Insulin Glulisine QD Insulin Glulisine TID (mmol/L) (N = 297) (N = 298) (N = 295) Baseline Number 295 295 294 Mean (SD) 6.58 (1.83) 6.85 (1.99) 6.65 (1.89) Median    6.40    6.50    6.40 Min:Max 2.9:16.1 2.9:13.8 2.9:13.4 Week 26 (LOCF) Number 295 295 294 Mean (SD) 6.59 (1.96) 6.66 (1.94) 6.71 (2.02) Median    6.20    6.40    6.50 Min:Max 2.9:15.3 2.9:16.1 2.7:16.2 Change from baseline to Week 26 (LOCF) Number 295 295 294 Mean (SD) 0.01 (2.15) −0.19 (2.52) 0.05 (2.47) Median    −0.15    −0.10    −0.20 Min:Max −7.0:7.9  −8.4:7.5  −7.5:10.7  LS Mean (SE)^(a) −0.23 (0.143) −0.21 (0.142) −0.06 (0.140) LS Mean difference (SE) of Lixisenatide vs.^(ab) — −0.01 (0.157) −0.17 (0.158) 95% CI — (−0.319 to 0.298) (−0.475 to 0.143) LOCF = Last observation carried forward. ^(a)Analysis of covariance (ANCOVA) model with treatment groups (lixisenatide, insulin glulisine QD, insulin glulisine TID), Visit 7 (Week −1) strata of HbA1c [<8.0, ≧8.0%], randomization strata of metformin use, and country as fixed effects and baseline fasting plasma glucose as a covariate ^(b)Difference in LS Mean between lixisenatide vs. insulin glulisine QD, or lixisenatide vs. insulin glulisine TID. The analysis included measurements obtained up to one day after the last injection of the investigational medicinal product. Patients with both baseline and Week 26 (LOCF) measurements are included.

TABLE 9 Mean change in insulin glargine dose (U) from baseline to Week 26 - mITT population Lixisenatide Insulin Glulisine QD Insulin Glulisine TID Insulin glargine dose (Units) (N = 297) (N = 298) (N = 295) Baseline Number 292 294 294 Mean (SD) 67.45 (31.68) 64.79 (32.09) 65.05 (27.01) Median    62.00    58.00    60.67 Min:Max 13.0:192.0 14.0:205.3 18.0: 204.0 Week 26 (LOCF) Number 292 294 294 Mean (SD) 67.22 (36.22) 63.89 (35.67) 61.16 (29.33) Median    60.00    54.00    57.00 Min:Max 14.0:224.7  9.3:254.0 14.0: 230.0 Change from baseline to Week 26 (LOCF) Number 292 294 294 Mean (SD) −0.22 (13.59) −0.91 (13.41) −3.89 (13.28) Median    −1.00    −1.33    −4.00 Min:Max −36.0: 60.0  −72.7:76.0  −56.0:35.3  LS Mean (SE)^(a)  0.70 (1.002) −0.06 (0.999) −3.13 (0.982) LS Mean difference (SE) of Lixisenatide vs.^(ab) —  0.76 (1.104)  3.83 (1.106) 95% CI — (−1.410 to 2.923) (1.658 to 6.001) LOCF = Last observation carried forward. ^(a)Analysis of covariance (ANCOVA) model with treatment groups (lixisenatide, insulin glulisine QD, insulin glulisine TID), Visit 7 (Week −1) strata of HbA1c [<8.0, ≧8.0%], randomization strata of metformin use, and country as fixed effects and baseline insulin glargine dose as a covariate. ^(b)Difference in LS Mean between lixisenatide vs. insulin glulisine QD, or lixisenatide vs. insulin glulisine TID. The analysis included measurements obtained up to the date of the last injection of the investigational medicinal product. Patients with both baseline and Week 26 (LOCF) measurements are included.

FIG. 3 shows the mean insulin glargine daily dose (U) by visit in the mITT population. FIG. 4 shows the mean daily insulin glulisine dose (U) by visit in the mITT population. FIG. 5 shows the mean total insulin dose (U) by visit in the mITT population

3.3 Safety

3.3.1 Treatment-Emergent Adverse Events

TABLE 10 Overview of adverse event profile: treatment emergent adverse events - Safety Insulin Insulin Glulisine Glulisine Lixisenatide QD TID (N = 298) (N = 301) (N = 294) Patients with any TEAE 221 (74.2%) 222 (73.8%) 236 (80.3%) Patients with any treatment 11 (3.7%) 11 (3.7%) 14 (4.8%) emergent SAE Patients with any TEAE  1 (0.3%) 0  2 (0.7%) leading to death Patients with any TEAE 15 (5.0%)  2 (0.7%)  3 (1.0%) leading to permanent treatment discontinuation TEAE: Treatment emergent adverse event, SAE: Serious adverse event n (%) = number and percentage of patients with at least one TEAE

TABLE 11 Number (%) of patients with TEAE(s) that occurred with PT≧3% in any treatment group by primary SOC and PT - Safety Insulin Insulin Primary System Organ Class Lixisenatide Glulisine QD Glulisine TM  Preferred Term n (%) (N = 298) (N = 301) (N = 294) Any class 221 (74.2%) 222 (73.8%) 236 (80.3%) Infections and infestations 70 (23.5%) 70 (23.3%) 81 (27.6%)  Nasopharyngitis 14 (4.7%) 21 (7.0%) 18 (6.1%)  Upper respiratory tract infection 8 (2.7%) 5 (1.7%) 11 (3.7%)  Influenza 5 (1.7%) 8 (2.7%) 14 (4.8%) Metabolism and nutrition disorders 111 (37.2%) 143 (47.5%) 157 (53.4%)  Hypoglycaemia 107 (35.9%) 140 (46.5%) 154 (52.4%) Nervous system disorders 32 (10.7%) 22 (7.3%) 29 (9.9%)  Headache 20 (6.7%) 8 (2.7%) 12 (4.1%) Gastrointestinal disorders 105 (35.2%) 26 (8.6%) 22 (7.5%)  Nausea 75 (25.2%) 5 (1.7%) 3 (1.0%)  Vomiting 26 (8.7%) 5 (1.7%) 6 (2.0%)  Diarrhoea 20 (6.7%) 10 (3.3%) 4 (1.4%) Investigations 69 (23.2%) 76 (25.2%) 92 (31.3%)  Blood glucose decreased 60 (20.1%) 67 (22.3%) 82 (27.9%) Injury, poisoning and procedural complications 14 (4.7%) 20 (6.6%) 28 (9.5%)  Accidental overdose 0 13 (4.3%) 20 (6.8%) TEAE: Treatment emergent adverse event, SOC: System organ class MedDRA 17.1 n (%) = number and percentage of patients with at least one TEAE Note: Table sorted by SOC internationally agreed order and decreasing frequency of PT in Lixisenatide main meal group.

3.3.2 Serious Treatment-Emergent Adverse Events

TABLE 12 Number (%) of patients with treatment emergent SAE presented by primary SOC and PT - Safety population Insulin Insulin Glulisine Glulisine Primary System Organ Class Lixisenatide QD TID  Preferred Term n (%) (N = 298) (N = 301) (N = 294) Any class 11 (3.7%) 11 (3.7%) 14 (4.8%) Infections and infestations 3 (1.0%) 1 (0.3%) 1 (0.3%)  Cellulitis 0 1 (0.3%) 1 (0.3%)  Erysipelas 1 (0.3%) 0 0  Penile infection 1 (0.3%) 0 0  Septic arthritis staphylococcal 1 (0.3%) 0 0 Neoplasms benign, malignant and 3 (1.0%) 0 3 (1.0%) unspecified (incl cysts and polyps)  Invasive ductal breast carcinoma 1 (0.3%) 0 1 (0.3%)  Pancreatic carcinoma metastatic 1 (0.3%) 0 0  Uterine cancer 1 (0.3%) 0 0  Basal cell carcinoma 0 0 1 (0.3%)  Neoplasm malignant^(a) 0 0 1 (0.3%) Metabolism and nutrition disorders 1 (0.3%) 2 (0.7%) 0  Hypoglycaemia 0 1 (0.3%) 0  Decreased appetite 1 (0.3%) 0 0  Dehydration 1 (0.3%) 1 (0.3%) 0 Nervous system disorders 1 (0.3%) 3 (1.0%) 2 (0.7%)  Cerebrovascular accident 1 (0.3%) 0 2 (0.7%)  Hypoglycaemic unconsciousness 0 2 (0.7%) 0  Neuritis cranial 0 1 (0.3%) 0 Cardiac disorders 1 (0.3%) 3 (1.0%) 5 (1.7%)  Angina pectoris 1 (0.3%) 0 1 (0.3%)  Cardiac failure chronic 0 0 1 (0.3%)  Cardiac failure congestive 0 0 1 (0.3%)  Myocardial ischaemia 0 0 1 (0.3%)  Angina unstable 0 1 (0.3%) 0  Atrial fibrillation 0 1 (0.3%) 0  Atrioventricular block complete 0 0 1 (0.3%)  Myocardial infarction 0 1 (0.3%) 0 Vascular disorders 0 0 1 (0.3%)  Hypertension 0 0 1 (0.3%) Gastrointestinal disorders 2 (0.7%) 0 0  Abdominal pain 1 (0.3%) 0 0  Epigastric discomfort 1 (0.3%) 0 0  Gastric ulcer haemorrhage 1 (0.3%) 0 0 Hepatobiliary disorders 1 (0.3%) 0 0  Hepatic mass 1 (0.3%) 0 0 Skin and subcutaneous tissue disorders 1 (0.3%) 0 1 (0.3%)  Diabetic bullosis 1 (0.3%) 0 0  Skin ulcer haemorrhage 0 0 1 (0.3%) Renal and urinary disorders 2 (0.7%) 0 0  Renal failure 1 (0.3%) 0 0  Renal failure acute 1 (0.3%) 0 0 Injury, poisoning and procedural complications 0 4 (1.3%) 1 (0.3%)  Accidental overdose 0 2 (0.7%) 1 (0.3%)  Ankle fracture 0 1 (0.3%) 0  Incisional hernia 0 1 (0.3%) 0 TEAE: Treatment emergent adverse event, SOC: System organ class, PT: Preferred term MedDRA 17.1 ^(a)basal cell cancer reported as “carcinoma on left side above hairline” n (%) = number and percentage of patients with at least one treatment emergent SAE. Note: Table sorted by SOC internationally agreed order and decreasing frequency of PT in Lixisenatide main meal group.

3.3.3 Adverse Events Leading to Permanent IMP Discontinuation

TABLE 13 Number (%) of patients experiencing TEAE(s) leading to permanent treatment discontinuation by primary SOC and PT during on-treatment period - Safety population Insulin Insulin Glulisine Glulisine Primary System Organ Class Lixisenatide QD TID  Preferred Term n (%) (N = 298) (N = 301) (N = 294) Any class 15 (5.0%) 2 (0.7%) 3 (1.0%) Neoplasms benign, malignant and 2 (0.7%) 0 0 unspecified (incl cysts and polyps)  Invasive ductal breast carcinoma 1 (0.3%) 0 0  Metastases to liver 1 (0.3%) 0 0  Metastases to peritoneum 1 (0.3%) 0 0  Pancreatic carcinoma metastatic 1 (0.3%) 0 0 Blood and lymphatic system disorders 1 (0.3%) 0 0  Lymphadenopathy 1 (0.3%) 0 0 Immune system disorders 0 0 1 (0.3%)  Seasonal allergy 0 0 1 (0.3%) Metabolism and nutrition disorders 2 (0.7%) 0 0  Hypoglycaemia 1 (0.3%) 0 0  Decreased appetite 1 (0.3%) 0 0  Dehydration 1 (0.3%) 0 0 Nervous system disorders 1 (0.3%) 1 (0.3%) 0  Headache 1 (0.3%) 0 0  Tremor 0 1 (0.3%) 0 Cardiac disorders 0 0 1 (0.3%)  Cardiac failure chronic 0 0 1 (0.3%) Vascular disorders 2 (0.7%) 0 0  Hot flush 1 (0.3%) 0 0  Thrombosis 1 (0.3%) 0 0 Respiratory, thoracic and mediastinal disorders 2 (0.7%) 0 0  Cough 1 (0.3%) 0 0  Nasal congestion 1 (0.3%) 0 0 Gastrointestinal disorders 11 (3.7%) 0 0  Nausea 4 (1.3%) 0 0  Vomiting 4 (1.3%) 0 0  Diarrhoea 1 (0.3%) 0 0  Abdominal pain 1 (0.3%) 0 0  Dyspepsia 1 (0.3%) 0 0  Ascites 2 (0.7%) 0 0  Epigastric discomfort 1 (0.3%) 0 0  Gastric ulcer haemorrhage 1 (0.3%) 0 0 Hepatobiliary disorders 1 (0.3%) 0 0  Hepatic mass 1 (0.3%) 0 0 Skin and subcutaneous tissue disorders 1 (0.3%) 0 1 (0.3%)  Diabetic bullosis 1 (0.3%) 0 0  Skin ulcer haemorrhage 0 0 1 (0.3%) Renal and urinary disorders 1 (0.3%) 0 0  Renal failure 1 (0.3%) 0 0 Investigations 0 1 (0.3%) 0  Blood glucose decreased 0 1 (0.3%) 0 TEAE: Treatment emergent adverse event, SOC: System organ class, PT: Preferred term MedDRA 17.1 n (%) = number and percentage of patients with at least one TEAE leading to permanent treatment discontinuation Note: Table sorted by SOC internationally agreed order and decreasing frequency of PT in Lixisenatide group.

3.3.4 Other Significant Adverse Events

Symptomatic Hypoglycemia

TABLE 14 Summary of symptomatic hypoglycemia meeting the protocol definition during the TEAE period - Safety population Insulin Insulin Glulisine Lixisenatide Glulisine QD TID Type (N = 298) (N = 301) (N = 294) Total patient years 144.6 148.3 146.2 Any symptomatic hypoglycemia Number of patients with 98 (32.9%) 117 (38.9%) 132 (44.9%) events, n (%) Number of patients with 67.8 78.9 90.3 events per 100 patient years¹ Number of events 332 395 600 Number of events per 100 229.6 266.4 410.4 patient years² Symptomatic hypoglycemia = symptomatic hypoglycemia as defined per protocol (accompanied by plasma glucose <60 mg/dL [3.3 mmol/L] or associated with prompt recovery to countermeasures if no plasma glucose was available). On-treatment period = the time from the first injection of the investigational medicinal product up to 3 days after the last injection of the investigational medicinal product. ¹Calculated as (number of patients with events * 100 divided by total exposure + 3 days in patient years). ²Calculated as (number of events * 100 divided by total exposure + 3 days in patient years).

Allergic Reaction

TABLE 15 Number (%) of patients with events adjudicated as allergic reaction by ARAC during the TEAE period - Safety population Relationship to MedDRA coded term study treatment (by ARAC diagnosis (PT) Lixisenatide Insulin Glulisine QD Insulin Glulisine TID ARAC) category for ARAC diagnosis (N = 298) (N = 301) (N = 294) All Any category Any event 3 (1.0%) 0 1 (0.3%) URTICARIA (HIVES) Urticaria 1 (0.3%) 0 0 OTHER ALLERGIC Rhinitis allergic 2 (0.7%) 0 1 (0.3%) REACTION Possibly Related to IMP Any category Any event 0 0 0 ARAC = Allergic Reaction Assessment Committee. IMP = Investigational medicinal product.

Pancreatitis

TABLE 16 Number (%) of patients with any event adjudicated as pancreatitis by PSAC during the TEAE period - Safety population Insulin Insulin Glulisine Glulisine Lixisenatide QD TID (N = 298) (N = 301) (N = 294) Total number of patients with 1 (0.3%) 0 0 any event adjudicated as pancreatitis by PSAC Acute pancreatitis 1 (0.3%) 0 0 Acute on chronic pancreatitis 0 0 0 Chronic pancreatitis 0 0 0 Unknown pancreatitis 0 0 0 PSAC = Pancreas Safety Assessment Committee.

Calcitonin

TABLE 17 Number (%) of patients with TEAE reported on the specific adverse event form for increased calcitonin (>=20 ng/L) - Safety population Preferred Lixisenatide Insulin Glulisine QD Insulin Glulisine TID Term (N = 298) (N = 301) (N = 294) Any 2 (0.7%) 0 1 (0.3%) Blood 2 (0.7%) 0 1 (0.3%) calcitonin increased TEAE: Treatment emergent adverse event

EXAMPLE 2

Advancing Basal Insulin Glargine with Prandial Lixisenatide QD vs Insulin Glulisine QD or TID in Obese T2DM: The GetGoal-Duo2 Evidence-Based Trial

To provide evidence on how to advance basal insulin (BI), we explored treatment options in poorly controlled Bl-treated (≧6 mo±1-3 OADs) obese adults with T2DM randomized to lixisenatide 20 μg QD (LIXI), insulin glulisine QD (GLU-1), or GLU TID (GLU-3), all added to insulin glargine (IG)±metformin, if HbA_(1c) remained >7-9% after a 12-week IG optimization run-in period stopping other OADs. Co-primary endpoints at 26 weeks were (1) non-inferiority (95% CI upper bound<0.4%) in HbA_(1c) reduction with LIXI vs GLU-1 and (2) for LIXI vs GLU-3, either non-inferiority in HbA_(1c) reduction (2a) OR superiority (one-sided α≦0.025) in body weight change (2b). FPG, PPG, IG dose, composite outcomes, AEs, and hypoglycemia were assessed. Each arm randomized 298 pts (T2DM duration 12 yrs, BI duration 3 yrs, weight ˜90 kg). All co-primary endpoints were met as LIXI was non-inferior to GLU-1 and GLU-3 for HbA_(1c) reductions and statistically superior to both for body weight loss (Table). Documented hypoglycemia was numerically and significantly lower with LIXI than with GLU-1 and GLU-3, respectively. In conclusion, BI plus LIXI, if tolerated, may become a preferred option to advance BI, attaining meaningful glycemic targets with less hypoglycemia and with weight loss compared with prandial insulin as Basal Plus or Basal/Bolus for difficult to control, obese, insulin-treated T2DM.

TABLE Lixisenatide 20 μg Insulin Glulisine Insulin Glulisine QD + Insulin QD + Insulin TID + Insulin Outcomes Glargine (n = 297) Glargine (n = 298) Glargine (n = 295) FPG, mg/dL Screening (start run-in) mean ± SD 165 ± 53 167 ± 52 171 ± 53 BL (end run-in) mean ± SD 119 ± 33 123 ± 36 120 ± 34 Week 26 (LOCF) mean ± SD 119 ± 35 120 ± 35 121 ± 36 LS mean ± SE change from BL −4 ± 3 −4 ± 3 −1 ± 3 LS mean [95% CI] treatment — 0 −3 difference [−6, 5]  [−9, 3]  2-h PPG post test meal, mg/dL* BL (end run-in) mean ± SD 254 ± 65 249 ± 63 262 ± 63 Week 26 (LOCF) mean ± SD 184 ± 70 220 ± 60 229 ± 69 LS mean ± SE change from BL −66 ± 11 −28 ± 11 −25 ± 11 LS mean [95% CI] treatment — −37 −40 difference [−59, −15] [−61, −19] HbA_(1c), % Screening (start run-in) mean ± SD  8.5 ± 0.7  8.5 ± 0.7  8.5 ± 0.8 BL (end run-in) mean ± SD  7.8 ± 0.6  7.7 ± 0.6  7.8 ± 0.6 Week 26 (LOCF) mean ± SD  7.2 ± 0.8  7.2 ± 0.8  7.0 ± 0.7 LS mean ± SE change from BL −0.6 ± 0.1 −0.6 ± 0.1 −0.8 ± 0.1 LS mean [95% CI] treatment −0.1^(†) 0.2^(†) difference — [−0.2, 0.1]  [0.1, 0.3] Insulin Glargine dose, U/day Screening (start run-in) mean ± SD  41 ± 22  40 ± 22 39 ± 2 BL (end run-in) mean ± SD  67 ± 32  65 ± 32  65 ± 27 Week 26 (LOCF) mean ± SD  67 ± 36  64 ± 36  61 ± 29 LS mean ± SE change from BL  0.7 ± 1.0 −0.1 ± 1.0 −3.1 ± 1.0 LS mean [95% CI] treatment 0.8 3.9 difference — [−1.4, 2.9]  [1.7, 6.0] Insulin Glulisine dose, U/day Week 26 (LOCF) mean — 10 20 Body Weight, kg BL mean ± SD  90.1 ± 17.4  88.4 ± 15.9  90.0 ± 17.2 Week 26 (LOCF) mean ± SD  89.4 ± 18.1  89.3 ± 16.3  91.3 ± 17.3 LS mean ± SE change from BL −0.6 ± 0.3  1.0 ± 0.3  1.4 ± 0.3 LS mean [95% CI] treatment — −1.7 −2.0 difference [−2.3, −1.1] [−2.6, −1.4] (p-value vs Lixisenatide) — (p < 0.0001)  (p < 0.0001)^(†) Documented Symptomatic Hypoglycemia at Week 26 % pts (p-value vs Lixisenatide) 31.5 37.5 (p = 0.144) 44.6 (p = 0.001) No. of events 325 384 595 No. of events/pt years 2.2 2.6 4.1 Estimated rate ratio — 0.8 0.5 Lixisenatide:Glulisine [95% CI] — [0.5, 1.1] [0.3, 0.7] (p-value vs Lixisenatide) (p = 0.123)  (p < 0.0001) Severe Hypoglycemia, no. of pts with 0 2 0 events Gastrointestinal AEs, n (%)^(‡) Nausea  75 (25) 5 (2) 3 (1) Diarrhea 20 (7) 10 (3)  4 (1) Vomiting 26 (9) 5 (2) 6 (2) *Subset of the mITT population treated with lixisenatide or insulin glulisine before breakfast; ^(†)co-primary endpoints; ^(‡)safety population. AEs, adverse events; BL, baseline; CI, confidence interval; FPG, fasting plasma glucose; HbA_(1c), glycated hemoglobin; LOCF, last observation carried forward; LS, least squares; mITT, modified intent-to-treat; PPG, postprandial glucose; QD, once daily; SD, standard deviation; SE, standard error; TID, thrice daily. n numbers are for the mITT population (all pts who received ≧1 dose of study medication, with both a baseline assessment and ≧1 post-baseline assessment). 

1. A pharmaceutical combination for use in glycemic control in a type 2 diabetes mellitus patient, said combination comprising (a) lixisenatide or/and a pharmaceutically acceptable salt thereof, (b) insulin glargine or/and a pharmaceutically acceptable salt thereof, and (c) optionally metformin or/and a pharmaceutically acceptable salt thereof.
 2. The pharmaceutical combination for use according to claim 1, wherein the type 2 diabetes mellitus to be treated is not adequately controlled with compound (b) and optionally compound (c) alone.
 3. The pharmaceutical combination for use according to claim 1, wherein the patient to be treated is obese.
 4. The pharmaceutical combination for use according to claim 1, wherein the patient to be treated has an age of at least 65 years.
 5. The pharmaceutical combination for use according to claim 1, wherein prior to the onset of therapy with the combination according to claim 1, the patient has a fasting plasma glucose of at least 9 mmol/L when treated with a basal insulin monotherapy or a basal insulin and one to three oral anti-diabetics alone selected from the group consisting of metformin, a sulfonylurea, a DPP-4 inhibitor or a glinide alone.
 6. The pharmaceutical combination for use according to claim 1, wherein prior to the onset of therapy with the combination according to claim 1, the patient has a fasting plasma glucose concentration in the range of 5.6 to 6.9 mmol/L or a fasting plasma glucose concentration of at least 6.6 mmol/L when treated with compound (b) and optionally compound (c) alone.
 7. The pharmaceutical combination for use according to claim 1, wherein prior to the onset of therapy with the combination according to claim 1, the patient has a HbA1c of at least 8.5% when treated with a basal insulin monotherapy or a basal insulin and one to three oral anti-diabetics alone selected from the group consisting of metformin, a sulfonylurea, a DPP-4 inhibitor or a glinide alone.
 8. The pharmaceutical combination for use according to claim 1, wherein prior to the onset of therapy with the combination according to claim 1, the patient has a HbAlc of at least 7.5% when treated with compound (b) and optionally compound (c) alone.
 9. The pharmaceutical combination for use according to claim 5, wherein the basal insulin is selected from insulin glargine, insulin detemir and isophane insulin (NPH insulin).
 10. The pharmaceutical combination for use according to claim 1, wherein the patient does not receive concomitant treatment with at least one of a sulfonylurea, a DPP-4 inhibitor and a glinide.
 11. The pharmaceutical combination for use according to claim 1, wherein in the type 2 diabetes mellitus patient to be treated has been diagnosed for at least 1 year or at least 2 years prior to the onset of a therapy with compounds (a), (b) and optionally (c).
 12. The pharmaceutical combination for use according to claim 1, wherein the administration of the combination comprises the steps: (i) administration of compounds (b) and (c) for at least 4 weeks, and (ii) continuing treatment by administration of compounds (a), (b) and (c), wherein the amount of compound (b) to be administered in step (i) is adjusted so that a predetermined fasting plasma glucose level or/and a predetermined self-monitored plasma glucose level is reached or at least approximated.
 13. The pharmaceutical combination for use according to claim 12, wherein the amount of compound (b) to be administered in step (i) is adjusted so that (I) a fasting plasma glucose level or/and a fasting self-monitored plasma glucose level of about 4.4 mmol/l to about 5.6 mmol/l, or/and (II) a self-monitored plasma glucose level (SMPG) of about 7.8 mmol/1 (or about 140 mg/dl) or less is reached or at least approximated.
 14. The pharmaceutical combination for use according to claim 13, wherein the self-monitored plasma glucose level in (II) is a 4-point self-monitored plasma glucose level or a 7-point self-monitored plasma glucose level.
 15. The pharmaceutical combination for use according to claim 1, wherein (a) lixisenatide or/and the pharmaceutically acceptable salt thereof is prepared for parenteral administration, (b) insulin glargine or/and or/and the pharmaceutically acceptable salt thereof is prepared for parenteral administration, or/and (c) metformin or/and the pharmaceutically acceptable salt thereof is prepared for oral administration. 